Healthcare Utilization Specialist

2 weeks ago


Charlottesville, Virginia, United States Commonwealth of Virginia Full time
Position Overview:
Under general supervision, the Utilization Management Registered Nurse acts as a pivotal resource in the Utilization Management framework. This role involves collaboration with physicians and various healthcare professionals to ensure adherence to regulatory standards and compliance.

Key Responsibilities:
  • Assessment of Medical Documentation: Review and analyze intricate medical records to ensure compliance with medical necessity criteria.
  • Clinical Data Interpretation: Exhibit proficiency in interpreting clinical information and applying Utilization Management tools effectively.
  • Collaboration with Healthcare Teams: Work closely with attending physicians, residents, and mid-level practitioners to facilitate patient care.
  • Critical Thinking and Judgement: Utilize sound judgement to identify cases requiring further review by external consultants and internal medical directors.
  • Insurance Coordination: Provide comprehensive and timely clinical information to insurance providers.
  • Appeals Management: Evaluate denied cases for potential appeals based on medical, contractual, and payer regulations.
  • External Collaboration: Conduct appeals with external organizations and consultants as necessary.
  • Case Management: Oversee appealed cases, including external reviews and resolution processes for billing issues.
  • Financial Support: Actively contribute to the financial objectives of the department.
  • Professional Development: Take responsibility for personal professional growth and assist in the development of colleagues.
  • Leadership Role: Demonstrate leadership qualities within the Utilization Management function.
  • Additional Duties: Other responsibilities may be assigned as needed.

Compensation: Competitive salary range based on experience.

Minimum Qualifications:
  • Education: Bachelor of Science in Nursing from an accredited institution.
  • Experience: Minimum of 2 years in an acute care hospital setting.
  • Licensure: Valid Registered Nurse license in the Commonwealth of Virginia.

Preferred Qualifications:
  • Experience: At least 3 years in diverse nursing roles within acute, medical-surgical, or adult care environments.

Physical Requirements:
Job entails prolonged periods of sitting, along with proficient communication, auditory, and visual skills. Attention to detail and legible writing are essential.

The Commonwealth of Virginia is committed to fostering a diverse workforce and encourages applications from individuals of all backgrounds. We are an equal opportunity employer and value diversity in our staff.

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